what’s new in dermatopathology melanocytic proliferationswhat’s new in dermatopathology...

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What’s New in DermatopathologyMelanocytic proliferations

Aleodor (Doru) Andea, MD, MBAAssociate Professor of Pathology and DermatologyDirector of Dermatopathology Molecular Diagnostic LaboratoryUniversity of MichiganAnn Arbor, [email protected]@DoruAndea

Disclosure of Relevant Financial Relationships

USCAP requires that all planners (Education Committee) in a position to

influence or control the content of CME disclose any relevant financial

relationship WITH COMMERCIAL INTERESTS which they or their

spouse/partner have, or have had, within the past 12 months, which relates to

the content of this educational activity and creates a conflict of interest.

Disclosure of Relevant Financial Relationships

USCAP requires that all faculty in a position to

influence or control the content of CME disclose any relevant financial

relationship WITH COMMERCIAL INTERESTS which they or their

spouse/partner have, or have had, within the past 12 months, which relates to

the content of this educational activity and creates a conflict of interest.

Dr. Aleodor Andea declares he has no conflict(s) of interest

to disclose.

Overview1. Case based presentation

2. Updates in molecular ancillary studies for thediagnosis of difficult melanocytic tumors (SNPmicroarrays)

3. Updates in diagnosis and prognosis of fewmelanocytic entities

• Why do we need more stuff?

MelanomaCommon nevus

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• A small proportion have ambiguous histology

Nevoid melanomaCommon nevus

?

• 40-year old woman with a papule on the right shoulder

• Clinical R/O BCC

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• Melanocytic neoplasm with borderline features between nevus and melanoma• Suspicious for nevoid melanoma

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What else we can do?

Molecular studies

Molecular studies

• Genomic instability in melanoma

Molecular studies

• Genomic instability in melanoma

• Detection of numerical abnormalities in the tumor genome (CGH/SNP and FISH)

Molecular studies

• Detection of numerical abnormalities in the tumor genome

• Mass spectrometry

• Gene expression profile

• Identification of mutations (TERT gene promoter)

Comparative Genomic Hybridization (CGH)/ Single Nucleotide Polymorphism (SNP) arrays

• Screens the entire genome for gains and losses in DNA material in one experiment

• Variants:• Array based CGH –Gains and Losses• Array based SNP –Gains, Losses and Loss of

Heterozygosity

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SNP arrays SNP arrays• Copy number changes

SNP arrays• Copy number changes

11p gain


• Allele peak


• Allele peak


• Allele peak

• Mutation data• BRAF• NRAS• PTEN• TP53

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Univ of Michigan Cohort

Melanoma

Nevus


Melanoma

Nevus


Melanoma

Nevus


Melanoma

Nevus

Compound nevus

• No gains or losses

• BRAF V600E

Primary melanoma

• 19 CNA

• 13 losses

• 6 gains

• BRAF V600E

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Metastatic melanoma

• 30 CNA• 25 gains• 2 losses• 3 CN-LOH

• BRAF V600K

• Chr 22 CN-LOH

• Chr 9p21 homozygous loss (CDKN2A)

• Chr 1p gain (NRAS)

• NRAS Q61R

• Chr 13q loss (BRCA2) • Chr 9p 21 homozygous loss• Chr 22 CN-LOH• Chr 1p gain (NRAS)• Chr 13q loss (BRCA2)

• NRAS Q61R

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Nevoid melanomaThis seems easy enough…

• No abnormalities – GOOD• Abnormalities – BAD

• Not that simple

Not all abnormalities are bad

• Some can be used to classify nevi

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28 y/o F, Lt Temple

3p loss (BAP-1 locus)

BRAF V600E

BAP-1 negative nevus (BAP-oma)

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BAP1 IHC10 days old AA newbornGiant congenital nevus with several nodules

CGHOncoScanTM

Affymetrix

Cop

y nu

mbe

r

• Result: Losses of whole chromosomes 3, 4, 5, 10, 11, 13, 14, 16, 17, 18, 21

10 days old AA newborn

Proliferative nodule in a congenital nevus

1 year old

More problems

• How many abnormalities do we require for a melanoma diagnosis

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Histologicalclassification

# of cases with at least one significant copy

number variation

Average # CNV

Nevi 0/6 (0%) 0

Atypical nevi 3/15 (20%) 1.6 (1-2)

Ambiguous 15/25 (60%) 6.3 (1-25)

Melanoma 35/39 (90%) 21.7 (1-69)

Alomari et al. Platform at USCAP meeting, Seattle WA, 2016

Sensitivity: 90%

Specificity: 87%

• >=3 abnormalities significant (but with exceptions)

• Whole chromosomal abnormalities in proliferative nodules

• Isolated homozygous deletion of 9p21 favors melanoma

• Others to come….

• >=3 abnormalities significant (but with exceptions)

• Whole chromosomal abnormalities in proliferative nodules

• Isolated homozygous deletion of 9p21 favors melanoma

• Others to come….

• Molecular pathologist job: Provide a comprehensive

interpretation

• Your job: Understand the report and communicate with

your molecular pathologist

Ultimate question

• Can CNV number and/or pattern predict adverse outcome in borderline lesions?

• Unfortunately not too many studies

Ambiguous cases with clinical follow up

65

3

0

1

2

3

4

5

6

7

8

9

10

Positive CNV Negative CNV

No adverse events Adverse events

N =14

0% Adverse events

33% Adverse events

Alomari et al. Platform at USCAP meeting, Seattle WA, 2016

Practical algorithm for use of molecular studies

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Melanocytic lesion

Histologic examination

Definitive diagnosis

No further testing Ambiguous lesion

Favor benign Favor malignant

Melanocytic lesion



No further testing

Borderline

Ambiguous lesion



Borderline

Molecular testing

Ambiguous lesion


Mol - Mol + Mol - Mol +


Borderline

Mol +Mol -

Ambiguous lesion


Melanoma

Mol -

Nevus

Mol + Mol - Mol +


Borderline

Mol +Mol -

Ambiguous lesion


Mol - Mol + Mol - Mol +


Borderline

Mol +Mol -

Borderline favor nevus

Borderline favor melanoma

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Ambiguous lesion


Mol -

Borderline

Mol +

Borderline

Mol - Mol +


Borderline

Mol +Mol -

Ambiguous lesion


Melanoma

Mol -

Nevus Borderline

Mol +

Borderline

Mol - Mol +

Melanocytic lesion



No further testing

Borderline

Mol +Mol -



Risk assessment

Ambiguous lesion


Melanoma

Mol -

Nevus Borderline

Mol +

Borderline

Mol - Mol +

Melanocytic lesion



No further testing

Borderline

Mol +Mol -



Excision with limited margins• Excision with margins appropriate

for depth• SLN

• Excision with margins appropriate for depth if possible

• +/- SLN

Cost and TAT

Cost and TAT

Test Range TAT

SNP/CGH array $1,800-$2,400 14-21 days

FISH $800-$1,200 3-7 days

Microarray vs. FISH

• Order Microarray if • Order FISH if

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Microarray vs. FISH

• Order Microarray if• Can afford

• Order FISH if

Microarray vs. FISH

• Order Microarray if• Can afford• Have enough material

• > 1mm2• >30%tumor purity• 10 unst @ 10microns

• Order FISH if

Microarray vs. FISH



• Can wait 2-3 weeks

• Order FISH if

Microarray vs. FISH




Advantage: higher sensitivity

• Order FISH if

Microarray vs. FISH





• Order FISH if• Microarray not covered

Microarray vs. FISH





• Order FISH if• Microarray not covered• Not enough material

• Only few slides• Superficial lesions• Tumor infiltrated by benign cells/

inflammation

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Microarray vs. FISH







inflammation

• Need faster TAT

Microarray vs. FISH







inflammation• Need faster TAT

Disadvantage: lower sensitivity, higher false positive (lower specificity)

Key points

• CNVs can assist in the diagnosis of melanocytic lesions

• Should be used only in ambiguous lesion

• Molecular data should not overturn histologic impression

• >=3 abnormalities – significant for melanoma

• Understand the molecular report

30 y/o male blue-colored plaque on the scalp with subcutaneous nodules Bx from the plaque

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Bx from the nodules

Large plaque-type blue nevus with subcutaneous cellular nodules

6 years later

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Melanoma ex cellular blue nevus

• Aka Malignant blue nevus

Common blue nevus

Cellular blue nevus

Common blue nevus

Cellular blue nevus Atypical cellular blue nevus

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Melanoma (MBN) arising in atypical cellular blue nevus

Costa S, Byrne M, Pissaloux D, et al. Melanomas Associated With Blue Nevi or Mimicking Cellular Blue Nevi: Clinical, Pathologic, and Molecular Study of 11 Cases Displaying a High Frequency of GNA11 Mutations, BAP1 Expression Loss, and a Predilection for the Scalp. The American journal of surgical pathology. 2016;40(3):368-377.

Costa S, Byrne M, Pissaloux D, et al. Melanomas Associated With Blue Nevi or Mimicking Cellular Blue Nevi: Clinical, Pathologic, and Molecular Study of 11 Cases Displaying a High Frequency of GNA11 Mutations, BAP1 Expression Loss, and a Predilection for the Scalp. The American journal of surgical pathology. 2016;40(3):368-377.

• Predilection for scalp

• Scalp lesions with GNA11 mutations (as opposed to GNAQ in other sites)

• Loss of BAP1 associated with scalp location and poor prognosis

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Blue nevi: 5Atypical blue nevi: 10Melanoma ex blue nevus: 9

Blue nevus/ Cellular Blue Nevus


Atypical Cellular Blue Nevus

Atypical blue nevi may show few aberrations





Melanoma

MBN without adverse outcome

MBN with adverse outcome

3p loss may have prognostic implications in MBN

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103

Study Case Loss of 3p21 Local Recur SLN Distant Mets DOD

Chan et al. 2016

20 No NP No 021 No NP No 022 Yes 0 Brain, spinal cord 123 Yes 0 Liver 124 Yes 0 No 026 Yes 1 Regional LN 0

Costa et al. 2016

1 Yes NA Liver 1

3 No NA Breast, widespread 1

6 Yes NA Widespread 0

Gerami et al. 2010 1 No 0 No 0

North et al. 20121 No 0 No 02 No 0 No 0

Held et al. 2012

D082 No NA No 0D017 No NA No 0D111 No NA No 0

D129 No 1 No 0

D029 Yes 1 NA No 0D073 No NA No 0D074 No NA No 0D163 Yes NA No 0

D173 Yes NA ? 1

Dai et al. 2016 1 Yes 0 Liver 0Maize et al. 2005 1 Yes 1 NA no 0

• 23 cases

• Median FU: 3.8 yrs (0.8-22)

• 12 BAP1 –retained

• 11 BAP1 –lost

104

Case# Case Loss of 3p21 Local Recur SLN Distant Mets DOD

Chan et al. 2016

20 No NP No 021 No NP No 022 Yes 0 Brain, spinal cord 123 Yes 0 Liver 124 Yes 0 No 026 Yes 1 Regional LN 0

Costa et al. 2016

1 Yes NA Liver 1

3 No NA Breast, widespread 1

6 Yes NA Widespread 0

Gerami et al. 2010 1 No 0 No 0

North et al. 20121 No 0 No 02 No 0 No 0

Held et al. 2012

D082 No NA No 0D017 No NA No 0D111 No NA No 0

D129 No 1 No 0

D029 Yes 1 NA No 0D073 No NA No 0D074 No NA No 0D163 Yes NA No 0

D173 Yes NA ? 1

Dai et al. 2016 1 Yes 0 Liver 0Maize et am. 2005 1 Yes 1 NA no 0

• BAP1 loss• 9/11 = 82%

• BAP1 retained• 2/12 = 17%

Key points

• MBN usually arise in a preexisting blue nevus

• BAP-1 loss: marker for adverse outcome

Important Information Regarding CME/SAMs

The Online CME/Evaluations/SAMs claim process will only be available on the USCAP website until September 30, 2017.

No claims can be processed after that date!

After September 30, 2017 you will NOT be able to obtain any CME or SAMs credits for attending this meeting.

PRESENTATION TITLE

QUESTIONS?

Aleodor (Doru) Andea, MD, MBA

[email protected]

@DoruAndea

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• 79 y/o man

• Pigmented lesion on left medial finger for 6 years

• Slowly growing

MELAN-A

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MITF

Current case Acral lentiginous MIS

Lentigo

• Recurrence after 4 years

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Acral lentiginous melanoma

Am J Dermatopathol 36 (2) February 2014

Kim JY, Choi M, Jo SJ, Min HS, Cho KH. Acral lentiginous melanoma: indolent subtype with long radial growth phase. Am J Dermatopathol. 2014;36(2):142-147.

• 13 patients• Bland proliferation of

melanocytes• Not sufficient for MIS

Kim JY, Choi M, Jo SJ, Min HS, Cho KH. Acral lentiginous melanoma: indolent subtype with long radial growth phase. Am J Dermatopathol. 2014;36(2):142-147.

What else we could have done? Fluorescence in situ hybridization

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FISH for melanocytic tumors

• Evaluate for copy number alterations

• Original panel:• 6p25 (RREB1) -gains• 6q23 (MYB) -losses• 11q13 (CCND1) -gains

• Expanded panel• 8q24 (MYC) -gains• 9p21 (CDKN2A) -homozygous loss

Fluorescence in situ hybridization

11q13 (CCND1) amplification

Key points

• When faced with acral pigmented lesions with histologically

subtle atypical ALWAYS ask for the clinical impression

Important Information Regarding CME/SAMs

The Online CME/Evaluations/SAMs claim process will only be available on the USCAP website until September 30, 2017.

No claims can be processed after that date!

After September 30, 2017 you will NOT be able to obtain any CME or SAMs credits for attending this meeting.

3/27/2017

23

PRESENTATION TITLE

QUESTIONS?

Aleodor (Doru) Andea, MD, MBA

[email protected]

@DoruAndea

what’s new in dermatopathology melanocytic proliferationswhat’s new in dermatopathology...

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